Nursing Diagnosis for CVA Patient: A Comprehensive Guide

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition characterized by the disruption of blood flow to the brain. This interruption deprives brain tissue of oxygen and essential nutrients, leading to rapid cell damage and potential long-term disabilities. Understanding the nuances of stroke and its management is paramount for healthcare professionals, especially nurses, who play a pivotal role in patient care and recovery. This guide delves into the crucial aspect of Nursing Diagnosis For Cva Patients, providing a comprehensive overview for effective assessment, intervention, and care planning.

Types of Stroke

Strokes are broadly classified into two primary categories: ischemic and hemorrhagic, each with distinct underlying mechanisms and treatment approaches.

Ischemic Strokes: These are the most prevalent type of stroke, accounting for approximately 87% of all cases. Ischemic strokes occur when there is a reduction or complete cessation of blood flow to a region of the brain. This blockage can arise from various sources, including:

• Thrombosis: Formation of a blood clot within a cerebral artery, often due to atherosclerosis (plaque buildup).
• Embolism: A blood clot or other debris (such as fatty deposits) that travels from another part of the body (commonly the heart or carotid arteries) and lodges in a cerebral artery, obstructing blood flow.
• Systemic Hypoperfusion: Reduced blood flow to all parts of the body, including the brain, often caused by conditions like severe hypotension or cardiac arrest.

The consequence of ischemia is rapid brain tissue damage. Deprived of oxygen and glucose, neurons cannot function and begin to die within minutes. Prompt recognition and treatment are crucial to minimize brain damage and subsequent neurological deficits.

Hemorrhagic Strokes: Hemorrhagic strokes, while less common, are often associated with higher morbidity and mortality rates. They result from the rupture of a blood vessel within the brain, leading to bleeding into the brain tissue or surrounding spaces. The causes of hemorrhagic stroke are diverse and include:

• Intracerebral Hemorrhage: Bleeding directly into the brain tissue, often caused by hypertension, cerebral amyloid angiopathy (protein deposits weakening blood vessels), or arteriovenous malformations (AVMs).
• Subarachnoid Hemorrhage: Bleeding into the space between the brain and the surrounding membrane (subarachnoid space), frequently caused by the rupture of a cerebral aneurysm (a weak bulge in a blood vessel wall).

The accumulation of blood in the brain tissue exerts pressure on surrounding brain structures, further damaging brain cells. This increased intracranial pressure (ICP) can lead to severe neurological compromise and complications.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are characterized by temporary disruptions in blood flow to the brain. The symptoms of a TIA are similar to those of a stroke but are transient, typically resolving within minutes to hours, and always within 24 hours, without causing permanent brain damage. TIAs are warning signs of a potential future stroke. Individuals with a history of TIAs are at a significantly elevated risk of experiencing a full stroke. Therefore, identifying and managing risk factors following a TIA is essential for stroke prevention.

Nursing Process for CVA Patients

The nursing process is a systematic approach to patient care, and it is particularly vital in the management of CVA patients due to the complex and rapidly changing nature of their condition. Patients who have experienced a stroke exhibit a wide spectrum of disabilities, influenced by the stroke’s severity, the time elapsed before treatment initiation, and pre-existing health conditions.

Initial care for stroke patients often necessitates admission to specialized units such as the Intensive Care Unit (ICU) or step-down units, where continuous monitoring and specialized interventions can be provided. Nurses in these settings often possess specialized certifications like the NIH Stroke Scale (NIHSS) certification, demonstrating their expertise in stroke patient assessment and management. The NIHSS is a standardized tool used to quantify the neurological deficit caused by a stroke.

Stroke symptoms can be dynamic, exhibiting subtle or rapid changes that require vigilant monitoring and critical thinking from nurses. Prompt nursing interventions are crucial to prevent neurological deterioration and optimize patient outcomes. In severe stroke cases, patients may experience significant and lasting disabilities, necessitating comprehensive care encompassing feeding, bathing, mobility, and all aspects of daily living. These long-term deficits can profoundly impact patients’ and their families’ emotional and psychological well-being, potentially leading to depression and diminished quality of life. Nurses play a crucial role in providing compassionate care, ensuring patient safety and dignity, and addressing both the physical and psychosocial needs of stroke survivors and their families throughout the recovery journey.

Nursing Assessment for CVA Patients

The cornerstone of effective nursing care for CVA patients is a thorough and ongoing nursing assessment. This assessment involves the systematic collection of physical, psychosocial, emotional, and diagnostic data to establish a comprehensive understanding of the patient’s condition and needs.

Review of Health History

A detailed review of the patient’s health history is crucial in identifying potential stroke risk factors, understanding the timeline of symptom onset, and guiding subsequent diagnostic and treatment decisions.

1. General Symptom Inquiry: Nurses should actively inquire about the presence of sudden onset symptoms, which are hallmark indicators of stroke. These symptoms include:

• Hemiparesis or Hemiplegia: Weakness (paresis) or paralysis (plegia) affecting the face, arm, and leg on one side of the body. This is often the most recognizable sign of stroke.
• Sensory Deficits: Numbness or tingling sensations (paresthesias) in the extremities, often on one side of the body.
• Dysphagia: Difficulty swallowing, which can lead to aspiration pneumonia and nutritional deficiencies.
• Visual Disturbances: Sudden loss of vision in one or both eyes, double vision (diplopia), or visual field deficits (such as hemianopia – loss of half of the visual field).
• Speech Difficulties:
  • Expressive Aphasia (Broca’s Aphasia): Difficulty producing speech, characterized by slow, labored speech and grammatical errors, while comprehension is relatively preserved.
  • Receptive Aphasia (Wernicke’s Aphasia): Difficulty understanding spoken language, leading to fluent but nonsensical speech, and impaired comprehension.
  • Dysarthria: Difficulty articulating words due to muscle weakness affecting speech production, resulting in slurred or mumbled speech.
• Ataxia: Unsteady gait and lack of coordination, often manifesting as stumbling or difficulty walking.
• Balance and Coordination Alterations: Sudden dizziness, vertigo, or loss of balance.
• Changes in Mental Status: Confusion, disorientation, decreased level of consciousness, or sudden behavioral changes.

2. Onset of Symptoms: Determining the precise time of symptom onset is critical. Stroke symptoms manifest abruptly. Nurses must ascertain when the symptoms first appeared and the last time the patient was known to be at their baseline neurological function. This time window is crucial for determining eligibility for time-sensitive interventions like thrombolytic therapy (alteplase).

3. Risk Factor Identification: Identifying stroke risk factors helps in understanding the underlying causes and implementing preventive measures. Key risk factors include:

• Age: Risk increases significantly with age, particularly after 55 years.
• Ethnicity: African Americans and Hispanics have a higher incidence of stroke compared to Caucasians.
• Gender: Males have a slightly higher risk of stroke overall, although stroke is more common in women after menopause.
• Prior Stroke or TIA: A history of stroke or TIA significantly increases the risk of future stroke events.

4. Medical History Review: A thorough medical history is essential to identify pre-existing conditions that contribute to stroke risk. Conditions commonly associated with ischemic stroke include:

• Hypertension: High blood pressure is a major risk factor, damaging blood vessels and promoting atherosclerosis.
• Obesity: Excess weight is linked to hypertension, diabetes, and hyperlipidemia, all stroke risk factors.
• Hypercholesterolemia: High cholesterol levels contribute to atherosclerosis and plaque formation in arteries.
• Diabetes Mellitus: Diabetes damages blood vessels and increases the risk of blood clots.
• Obstructive Sleep Apnea: Sleep apnea is associated with hypertension, atrial fibrillation, and other cardiovascular risks.
• Heart Disease: Conditions like coronary artery disease, heart failure, and valvular heart disease increase the risk of embolic stroke.
• Atrial Fibrillation: This irregular heart rhythm increases the risk of blood clot formation in the heart, which can then travel to the brain.
• COVID-19 Infection: Recent studies have linked COVID-19 infection to an increased risk of stroke, likely due to hypercoagulability and inflammation.

5. Family History: A family history of stroke, particularly in immediate family members and at a young age (before 65), increases an individual’s stroke risk. Genetic conditions like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy), a rare inherited vascular disease, can also predispose to stroke.

6. Medication Review: A comprehensive medication review is essential, noting both prescribed and over-the-counter medications.

• Estrogen-containing Medications: Birth control pills and hormone replacement therapy containing estrogen can increase stroke risk, particularly in women who smoke or have other risk factors.
• Blood Pressure Medications: Non-adherence to prescribed antihypertensive medications can lead to uncontrolled hypertension and elevated stroke risk.
• Anticoagulants and Antiplatelets: Medications like aspirin, heparin, enoxaparin, and warfarin, while used to prevent blood clots, can also indicate pre-existing conditions that increase stroke risk (e.g., atrial fibrillation, history of blood clots).

7. Illegal Substance Use: The use of illicit drugs, particularly stimulants like amphetamines, cocaine, and heroin, is linked to increased stroke risk due to their effects on blood pressure, heart rate, and blood vessel constriction.

8. Lifestyle Assessment: Lifestyle factors significantly impact stroke risk. Nurses should assess:

• Dietary Habits: A diet high in cholesterol, saturated fats, and trans fats promotes atherosclerosis.
• Physical Activity Levels: Insufficient physical exercise contributes to obesity, hypertension, and diabetes.
• Alcohol Consumption: Excessive alcohol intake increases blood pressure and can contribute to atrial fibrillation.
• Smoking: Smoking damages blood vessels, increases blood pressure, and promotes blood clot formation, significantly elevating stroke risk.

Physical Assessment

A focused physical assessment is crucial for identifying stroke signs and assessing the extent of neurological deficits.

1. F.A.S.T. Recognition: Educate patients and families about the F.A.S.T. acronym, a simple and effective tool for recognizing stroke symptoms:

• F – Face Drooping: Ask the person to smile. Does one side of the face droop?
• A – Arm Weakness: Ask the person to raise both arms. Does one arm drift downward?
• S – Speech Difficulty: Ask the person to repeat a simple sentence. Is their speech slurred or strange?
• T – Time to call 911: If any of these signs are present, call emergency services immediately. Time is critical in stroke treatment.

2. ABCs Assessment: Prioritize assessment of Airway, Breathing, and Circulation. Stroke patients are at risk of aspiration due to dysphagia and respiratory compromise secondary to increased intracranial pressure.

3. Stroke Assessment (NIHSS): Administer a standardized stroke assessment tool, such as the National Institutes of Health Stroke Scale (NIHSS), to quantify neurological deficits. The NIHSS evaluates:

• Level of Consciousness (LOC): Alertness, orientation, and responsiveness.
• Eye Movements (Gaze): Ability to follow commands with eyes and presence of gaze deviation.
• Visual Fields: Assessment of peripheral vision and visual field cuts.
• Facial Palsy: Assessment of facial symmetry and muscle weakness.
• Motor Function (Arms and Legs): Strength and motor control in upper and lower extremities.
• Limb Ataxia: Coordination and balance testing.
• Sensory Function: Response to touch and pinprick stimuli.
• Language (Aphasia): Assessment of speech comprehension and production.
• Dysarthria: Assessment of speech articulation.
• Neglect/Inattention: Awareness of stimuli on both sides of the body.

4. Vital Signs Monitoring: Closely monitor vital signs, particularly blood pressure. Hypertension is common in acute stroke. However, rapid blood pressure reduction can be detrimental, especially in ischemic stroke, as it can compromise cerebral perfusion. Blood pressure management in stroke is nuanced and depends on the stroke type and treatment plan.

Diagnostic Procedures

Diagnostic procedures are essential to confirm the diagnosis of stroke, differentiate between ischemic and hemorrhagic stroke, identify the stroke’s cause, and guide treatment strategies.

1. Blood Glucose Level Check: Immediately check blood glucose levels using a fingerstick. Hypoglycemia (low blood sugar) can mimic stroke symptoms. Ruling out hypoglycemia is crucial in the initial assessment.

2. Brain Imaging: Neuroimaging is paramount in stroke diagnosis.

• Non-contrast Head CT Scan: This is the initial imaging modality of choice in suspected stroke. It rapidly differentiates between ischemic and hemorrhagic stroke. Hemorrhage is readily visible on CT, while early ischemic changes may be subtle or not apparent initially.
• CT Angiography (CTA) and CT Perfusion (CTP) Scanning: CTA visualizes blood vessels and can identify large vessel occlusions, which are targets for thrombectomy. CTP assesses cerebral blood flow and tissue viability, helping to identify ischemic penumbra (potentially salvageable brain tissue).
• Magnetic Resonance Imaging (MRI): MRI is more sensitive than CT in detecting early ischemic changes and provides detailed anatomical information. Diffusion-weighted imaging (DWI) MRI is particularly useful in identifying acute ischemic stroke within minutes of symptom onset.
• Carotid Duplex Ultrasound: This non-invasive ultrasound assesses the carotid arteries in the neck for stenosis (narrowing) due to plaque buildup, a common cause of ischemic stroke.
• Digital Subtraction Angiography (DSA): DSA is an invasive angiography procedure that provides detailed images of cerebral blood vessels. It is typically reserved for specific situations, such as evaluating aneurysms or AVMs.

3. Laboratory Tests: Blood tests help identify underlying causes and contributing factors to stroke. Common lab tests include:

• Complete Blood Count (CBC): Evaluates red blood cell count (polycythemia can increase blood viscosity), white blood cell count (infection), and platelet count (thrombocytopenia or thrombocytosis can affect clotting).
• Cardiac Biomarkers (Troponin, CK-MB): Assess for cardiac injury, as underlying cardiac conditions like myocardial infarction can be associated with stroke.
• Toxicology Screen: Rules out drug intoxication as a cause of stroke-like symptoms.
• Fasting Lipid Profile: Evaluates cholesterol and triglyceride levels, identifying hyperlipidemia as a risk factor.
• Coagulation Studies (PT/INR, PTT): Assess blood clotting function, especially before administering anticoagulants or antiplatelet agents.

4. Pregnancy Test: For female patients of childbearing age, a urine pregnancy test is performed before considering fibrinolytic therapy (alteplase), as the safety of alteplase in pregnancy has not been established.

5. Electrocardiogram (ECG): An ECG is performed to assess for cardiac arrhythmias, particularly atrial fibrillation, a major cause of cardioembolic stroke. Identifying atrial fibrillation is crucial for initiating anticoagulation therapy to prevent future strokes.

Nursing Interventions for CVA Patients

Nursing interventions are crucial in the acute phase of stroke management and throughout the rehabilitation process. These interventions aim to restore brain perfusion, prevent complications, support recovery, and maximize functional outcomes.

Restore Brain Perfusion

The primary goal in acute ischemic stroke management is to rapidly restore blood flow to the ischemic brain tissue.

1. Initial Evaluation and Diagnostic Imaging Preparation: Upon arrival in the emergency department, patients with suspected stroke should undergo immediate neurological evaluation and preparation for STAT non-contrast head CT scan within 25 minutes of arrival and completed within 45 minutes. Rapid imaging is essential to confirm stroke diagnosis and differentiate between ischemic and hemorrhagic stroke, guiding further treatment.

2. Restore Adequate Blood Flow (Thrombolysis): For eligible patients with confirmed ischemic stroke, initiate alteplase (tissue plasminogen activator – tPA) as rapidly as possible. Alteplase is a thrombolytic medication that dissolves blood clots and can significantly improve outcomes if administered within a specific time window. The American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend administering IV alteplase within 3 hours of symptom onset in carefully selected patients and up to 4.5 hours in certain eligible patients. Alteplase is contraindicated in hemorrhagic stroke due to the risk of exacerbating bleeding.

3. Neurological Status Monitoring: Frequent and meticulous neurological assessments are paramount. Nurses should:

• Monitor Pupil Size and Reactivity: Changes in pupil size or reactivity can indicate increased intracranial pressure or neurological deterioration.
• Assess Speech, Memory, and Cognition: Monitor for changes in language function, orientation, and cognitive abilities.
• Observe for Mood Changes: Stroke can affect mood and emotional regulation.
• Assess Bilateral Strength and Coordination: Regularly evaluate motor strength and coordination in all extremities.

4. Medication Administration: Administer medications as prescribed to manage secondary complications and optimize neurological recovery.

• Blood Pressure Medications: Manage blood pressure according to established guidelines. In the acute phase of ischemic stroke, permissive hypertension may be allowed to maintain cerebral perfusion, unless thrombolysis is planned or performed. For hemorrhagic stroke, more aggressive blood pressure control is typically indicated.
• Seizure Prophylaxis: Anticonvulsant medications may be initiated, particularly in hemorrhagic stroke or strokes involving the cerebral cortex, to prevent seizures. Seizures can worsen neurological damage and increase ICP.
• Stool Softeners/Laxatives: Prevent constipation and straining during bowel movements, as straining can increase ICP.

5. Blood Pressure Management: Blood pressure management in acute stroke is complex and depends on the stroke type and treatment strategy.

• Ischemic Stroke: For patients receiving IV alteplase, maintain blood pressure below 180/105 mm Hg for the first 24 hours post-treatment. For patients not receiving thrombolysis, current guidelines suggest maintaining moderate hypertension in the acute phase, avoiding overly aggressive blood pressure lowering. The goal is to maintain cerebral perfusion while minimizing the risk of hemorrhage.
• Hemorrhagic Stroke: More aggressive blood pressure reduction is typically indicated, with a target systolic blood pressure of around 140 mmHg in many cases. Close blood pressure monitoring and titration are essential.

6. Mechanical Thrombectomy Preparation: For patients with large vessel occlusion ischemic stroke, mechanical thrombectomy may be indicated. This procedure involves using a catheter inserted through the groin to physically remove or dissolve the clot obstructing a major cerebral artery. Nurses prepare the patient and family for the procedure, ensuring informed consent is obtained and addressing any questions or concerns.

7. Endovascular Techniques Preparation: For patients with carotid artery stenosis, endovascular procedures like carotid endarterectomy (surgical removal of plaque from the carotid artery) or carotid artery stenting (placement of a stent to open the narrowed artery) may be considered to improve blood flow and reduce future stroke risk. Nurses provide pre- and post-procedure care for patients undergoing these interventions.

Stroke Recovery and Prevention

Rehabilitation and secondary stroke prevention are crucial components of long-term stroke care.

1. Stroke Rehabilitation Referral: Early and comprehensive rehabilitation is essential to optimize functional recovery. Refer patients to:

• Speech Therapy: For patients with aphasia, dysarthria, or dysphagia.
• Physical Therapy: To address motor deficits, improve mobility, balance, and coordination.
• Occupational Therapy: To improve activities of daily living (ADLs), fine motor skills, and cognitive function.
• Cognitive Therapy: To address cognitive deficits, such as memory problems, attention deficits, and executive dysfunction.

2. Speech Deficit Management Education: For patients with speech and language deficits, nurses reinforce speech therapy recommendations and educate patients and families on strategies to facilitate communication:

• Communication Partner Training: Educate communication partners (family, caregivers) on effective communication strategies, such as speaking slowly and clearly, using visual aids, and confirming understanding.
• Speech Practice: Encourage regular speech practice using flashcards, books, computer programs, and apps.
• Alternative Communication Methods: Introduce communication boards, pen and paper, or communication apps to support communication needs.

3. Medication Education: Provide thorough education on prescribed medications upon discharge, including:

• Anticoagulants: For patients with atrial fibrillation or other indications for anticoagulation to prevent blood clots. Examples include apixaban, dabigatran, rivaroxaban, and warfarin. Educate on medication adherence, monitoring (INR for warfarin), and potential side effects (bleeding risk).
• Antiplatelet Agents: Aspirin or other antiplatelet agents may be prescribed to prevent secondary stroke by inhibiting platelet aggregation.
• Blood Pressure Medications: Educate on the importance of blood pressure control and adherence to prescribed antihypertensive medications (diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, etc.).

4. Safety Strategies Implementation: Address safety concerns related to motor and sensory deficits.

• Fall Prevention: Implement fall precautions, ensuring bed rails are up, bed alarms are activated, and call lights are within reach. Educate patients and families about fall risks and home safety modifications.
• Assistive Devices: Provide and educate on the use of assistive devices for mobility (walkers, canes), ADLs (dressing aids, grab bars), and eating (adaptive utensils).

5. Support Group Encouragement: Refer patients and families to local stroke support groups. Support groups provide emotional support, peer interaction, and valuable resources for stroke survivors and caregivers.

6. Lifestyle Modification Promotion and Education: Educate patients on modifiable lifestyle factors to reduce secondary stroke risk:

• Dietary Modifications: Recommend a heart-healthy diet low in processed foods, saturated and trans fats, and sodium, and rich in fruits, vegetables, and whole grains.
• Regular Exercise: Encourage daily physical activity as tolerated, aiming for at least 30 minutes of moderate-intensity exercise most days of the week.
• Smoking Cessation: Strongly advise smoking cessation and provide resources and support for quitting.
• Limited Alcohol Consumption: Recommend limiting alcohol intake.
• Healthy Weight Maintenance: Encourage weight management to achieve and maintain a healthy weight.

7. Treatment Regimen Adherence: Emphasize the importance of adhering to treatment regimens for underlying comorbidities like hypertension, diabetes, and hypercholesterolemia. Ensure patients understand medication schedules, follow-up appointments, and necessary diagnostic testing.

Nursing Care Plans for CVA Patients

Nursing care plans are essential tools for organizing and prioritizing nursing care for CVA patients. They are based on identified nursing diagnoses and guide interventions to achieve both short-term and long-term patient goals. Here are examples of common nursing diagnoses and associated care plan components for stroke patients:

Impaired Verbal Communication

Stroke frequently affects communication abilities, resulting in difficulties with speech comprehension, expression, and the physical production of meaningful speech.

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Prolonged cerebral occlusion
• Dysarthria (weakened muscles for speech)
• Aphasia (impaired language ability)

As evidenced by:

• Slurred speech
• Nonverbal communication
• Difficulty forming words
• Difficulty expressing thoughts
• Slow response due to delayed comprehension
• Extremity weakness/paralysis hindering writing/typing

Expected Outcomes:

• Patient will establish a communication method to express needs and thoughts.
• Patient will participate in speech therapy to improve communication skills.
• Patient will utilize communication resources and devices effectively.

Assessment:

1. Aphasia Type: Determine the type of aphasia (global, Wernicke’s, Broca’s) to understand specific communication deficits and guide interventions.
2. Communication Methods: Observe and document the patient’s existing communication methods (gestures, signals, sounds). Involve family to understand patient-specific communication cues.

Interventions:

1. Short, Direct Sentences: Speak clearly, face the patient, and use short, direct sentences. Use “yes” or “no” questions for easier comprehension.
2. Alternative Communication: Utilize writing, drawing, flashcards, or communication boards as needed. Establish a simple communication system (thumbs up/down, eye blinks).
3. Speech Therapy Referral: Encourage and facilitate speech-language therapy. Speech therapy is crucial for language recovery and teaching compensatory strategies and assistive communication devices.
4. Family Involvement: Involve family in communication therapy and teach them communication techniques to support the patient.

Ineffective Cerebral Tissue Perfusion

Disrupted blood flow in stroke leads to oxygen deprivation and brain tissue damage.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to:

• Interruption of cerebral blood flow
• Thrombus formation
• Arterial occlusion
• Cerebral edema
• Hemorrhage

As evidenced by:

• Altered mental status
• Blurred vision
• Slurred speech
• Extremity weakness

Expected Outcomes:

• Patient will recognize stroke symptoms and seek prompt medical attention.
• Patient will demonstrate improved cerebral perfusion (vital signs within parameters).
• Patient will show improvement in stroke deficits (speech, weakness, swallowing) by discharge.

Assessment:

1. Baseline Presentation: Determine the patient’s baseline neurological status before symptom onset to assess for changes and guide interventions. Time of symptom onset is critical for thrombolytic eligibility.
2. Neurological Assessments: Perform frequent stroke scale assessments (NIHSS) to monitor LOC, visual changes, motor function, sensory changes, and speech/language deficits.
3. Brain Imaging Review: Review CT or MRI results to confirm stroke type (ischemic/hemorrhagic) and guide treatment.

Interventions:

1. Blood Pressure Management: Maintain blood pressure within ordered parameters to optimize cerebral perfusion. Permissive hypertension may be indicated in ischemic stroke (unless thrombolysis is used), while tighter control is needed in hemorrhagic stroke.
2. Thrombolytic Administration: Administer thrombolytics (alteplase) as ordered for ischemic stroke within the appropriate time window (if eligible and no contraindications).
3. Risk Factor Education: Educate patients on modifiable stroke risk factors (hypertension, heart disease, diabetes, smoking, stress) and lifestyle changes for secondary prevention.
4. FAST Acronym Education: Educate patients and families on stroke symptoms using the FAST acronym to promote early recognition and prompt action (“Time is tissue”).

Risk For Injury

Stroke-related neurological deficits, including perceptual issues, impaired judgment, and motor weakness, increase the risk of falls and injuries.

Nursing Diagnosis: Risk For Injury

Related to:

• Impaired judgment
• Spatial-perceptual deficits
• Weakness
• Poor motor coordination
• Poor balance
• Impaired time concept
• Impaired sensory awareness
• Dysphagia
• Communication difficulties
• Hemiplegia
• Short attention span
• Impulsivity

Expected Outcomes:

• Patient will remain free from falls.
• Patient will maintain intact skin integrity.
• Caregivers will create a safe environment to prevent patient injury.

Assessment:

1. Deficit Determination: Assess specific deficits related to the stroke location (e.g., right-brain stroke: spatial deficits, left-brain stroke: swallowing/speech issues).
2. Sensory Awareness: Assess sensory function (pain, temperature, pressure) to identify risk of skin breakdown and injury.
3. Neglect and Visual Disturbances: Assess for unilateral neglect and visual field deficits (hemianopia), which increase injury risk.

Interventions:

1. Bed and Chair Alarms: Use bed and chair alarms, especially for impulsive patients (right-brain stroke), to prevent falls.
2. Eating Assistance: Assist with meals, provide appropriate diet modifications (dysphagia diet), and ensure safe swallowing to prevent aspiration.
3. Environment Scanning Education: Teach patients with neglect or visual deficits to scan their environment from left to right to improve awareness and safety.
4. Frequent Skin Assessment and Turning: Turn and reposition patients every 2 hours, assess skin frequently, and ensure pressure relief to prevent skin breakdown in immobile or insensate areas.

Self-Care Deficit

Stroke-related motor and cognitive impairments can significantly impact the ability to perform self-care activities.

Nursing Diagnosis: Self-Care Deficit

Related to:

• Neurobehavioral manifestations
• Weakness
• Musculoskeletal impairment
• Cognitive dysfunction
• Decreased motivation
• Impaired physical mobility
• Unilateral neglect

As evidenced by:

• Inability to complete cleansing activities independently
• Inability to dress/undress independently
• Impaired ability to use utensils, prepare food, or self-feed
• Inability to access bathroom or perform toileting

Expected Outcomes:

• Patient will maintain skin integrity and be free from body odor.
• Patient will verbalize successful use of assistive bathing methods/devices.
• Patient will report dignity and satisfaction with assisted bathing.
• Patient will dress and perform ADLs to optimal potential.
• Patient will demonstrate competence using assistive devices.
• Patient will feed self safely and effectively.
• Patient will remain continent and free from skin irritation related to incontinence.

Assessment:

1. Functional Ability Assessment: Assess functional abilities and limitations in mobility, sensation, cognition, and emotions to plan appropriate care and rehabilitation.
2. Patient Preferences: Respect patient preferences and comfort levels in self-care activities to promote cooperation and build confidence.
3. Risk Assessments: Perform routine risk assessments:
   • Fall risk (Morse Fall Scale)
   • Skin breakdown risk (Braden Scale)
   • Swallowing risk (bedside swallow study)

Interventions:

1. Toileting Schedule: Establish a toileting schedule and administer stool softeners to prevent constipation and promote bowel regularity.
2. Independence Encouragement: Encourage independence in ADLs to maximize autonomy and self-esteem.
3. Adequate Meal Time: Allow sufficient time for meals, especially for patients with dysphagia or feeding difficulties.
4. Adaptive Equipment Assistance: Provide and instruct on the use of adaptive equipment for dressing, bathing, grooming, and eating.
5. Physical/Occupational Therapy Consult: Consult with physical and occupational therapy for rehabilitation and training in ADLs and assistive device use.

Unilateral Neglect

Unilateral neglect, often associated with right-brain stroke, involves a lack of awareness of one side of the body and the environment.

Nursing Diagnosis: Unilateral Neglect

Related to:

• Disease process
• Brain trauma/damage
• Cerebral tissue ischemia

As evidenced by:

• Altered safety behavior on neglected side
• Failure to move eyes to neglected side
• Inability to move limbs on neglected side
• Difficulty grooming neglected side
• Unawareness of neglected limb position

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect.
• Patient will care for both body sides and protect the neglected side from harm.
• Patient will return to highest possible functional level.

Assessment:

1. Neglect Signs: Assess for signs of neglect: ignoring one side of the body, leaning to one side, eating from only one side of the plate, failing to respond to stimuli on the neglected side.
2. Awareness Level: Assess the patient’s awareness of their neglect and ability to learn compensatory strategies.
3. Skin Assessment (Neglected Side): Assess skin on the neglected side for injury or breakdown due to lack of awareness and repositioning.

Interventions:

1. Fall Precautions: Implement fall precautions due to one-sided weakness and neglect. Ensure bed alarm use and call light accessibility.
2. Assistive Device Encouragement: Encourage the use of assistive devices to compensate for neglect and improve safety.
3. Neutral Body Positioning: Instruct patient to maintain neutral body alignment and change positions regularly to prevent pain, joint issues, and contractures.
4. Object Placement (Unaffected Side): Place belongings and approach patient from the unaffected side to promote awareness and safety.
5. Rehabilitation Program Coordination: Coordinate transfer to rehabilitation programs (physical, occupational, speech therapy) to address neglect and optimize functional recovery.

References

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